Forms and Notices
|
Document |
Purpose |
Timeline |
Completed by |
Send to |
|---|---|---|---|---|
|
Notifies new employees about California Workers’ Compensation rights and benefits. Ensures employees know what to do in case of workplace injury. |
Either at the time of hire or by the end of the first pay period |
NA |
NA |
|
|
Outlines employee benefits under Workers’ compensation |
NA |
NA |
NA |
|
|
Allows an employee to pre-designate a personal physician for treatment of work-related injuries or illnesses |
NA |
The employee and the doctor. Primary Treating Physician must agree. |
NA |
|
|
eSU-17 (complete electronically on the EHS website) |
To be completed for any on campus injury, illness, accident or exposure involving a Stanford University employee or working student.
**Except for incidents related to stress or mental health** |
To be completed within 24 hours |
Supervisor & Injured Worker |
Complete elecronically on the EHS website
|
|
eSU-17B (complete electronically on the EHS website) |
It is to be completed for any on campus injury, illness, accident or exposure involving a person other than a Stanford employee. |
To be completed within 24 hours |
Involved Party &/or University Contact |
Complete electronically on the EHS website |
|
This form notifies employees of their right to file a Workers’ compensation claim. They may file by completing and signing the form. |
To be provided to the employee within 24 hours or one working day of notice or knowledge of injury |
Supervisor or Department Administrator per first page instruction sheet. Employee completes and signs only if filing a claim. |
"SECURE: Email to Risk Management at: incidentreport@stanford.edu or workerscomp@stanford.edu".
|
|
|
Completed (must be typed) when one or more workdays are lost or when treatment is provided in a medical facility. |
Submitted to Risk Management within 48 hours |
Supervisor, HR, or department Administrator (Not completed by the employee) |
"SECURE: Email to Risk Management at: incidentreport@stanford.edu or workerscomp@stanford.edu". |